Hospital Use Of Mechanical Prophylaxis For Venous Thromboembolism: Is The Juice Worth The Squeeze?

Hospital Use of Mechanical Prophylaxis for Venous Thromboembolism: Is the Juice Worth the Squeeze?

Dr. Paul J Grant, MD^*¹; Dr. M. Todd Greene, PhD, MPH¹; Daniel Nielsen, MS¹; Dr. Lakshmi Swaminathan, MD²; Dr. Steven J Bernstein, MD, MPH^1,3 and Dr. Scott A Flanders, MD¹, (1)University of Michigan, Ann Arbor, MI, (2)Oakwood Medical Center, Dearborn, MI, (3)VA Ann Arbor Healthcare System, Ann Arbor, MI

Meeting: Hospital Medicine 2016, March 6-9, San Diego, Calif.

Abstract Number: 214

Category: Research

Sub-Category: Quality Improvement

Keywords: Mechanical Prophylaxis and Venous Thromboembolism

Background:

Current national guidelines recommend using mechanical methods for venous thromboembolism (VTE) prophylaxis in hospitalized medical patients at elevated risk for thrombosis who have a contraindication to pharmacologic prophylaxis. Additionally, it is recommended to avoid the use of mechanical prophylaxis for patients who are at low risk for VTE. The Michigan Hospital Medicine Safety Consortium, a multihospital quality collaborative, assessed VTE risk and prophylaxis strategies among medical patients in a diverse group of Michigan hospitals. We sought to determine if use of mechanical prophylaxis was consistent with nationally recognized best practices.

Methods:

Using web-based data entry, a trained abstractor at each of 52 participating hospitals collected detailed demographic and clinical data including all known risk factors for VTE and use of mechanical and pharmacologic prophylaxis among a sample of medical patients hospitalized from December 2011 to September 2015. For this analysis, patients were excluded if they were: <18 years of age; admitted for VTE, surgery, or comfort care; directly admitted to the ICU; or on systemic anticoagulation. VTE risk stratification was determined using the Padua risk assessment model. We determined mechanical prophylaxis usage among low-risk patients, high-risk patients with and without a contraindication to pharmacologic prophylaxis, and use in combination with pharmacologic prophylaxis.

Results:

VTE risk assessment and prophylaxis measures were collected on 78,794 patients. Of these, 32,078 patients (41.7%) had mechanical prophylaxis, almost exclusively delivered via pneumatic compression devices, ordered upon hospital admission. Mechanical prophylaxis was ordered for 40.1% of low-risk patients (n=66,191) and for 43.9% of high-risk patients (n=12,603). For patients at high-risk for VTE but with a contraindication for pharmacologic prophylaxis (n=1,663), 67.2% had mechanical prophylaxis ordered. The combination of pharmacologic and mechanical prophylaxis was ordered in 21.8% of all patients with similar rates used in high-risk (24.1%) and low-risk patients (21.4%). Of the total number of patients who had mechanical prophylaxis ordered on admission, only 5.2% (1,663/32,078) had an indication that was consistent with national guideline recommendations.

Conclusions:

In a large cohort of hospitalized medical patients, the vast majority of patients who were prescribed mechanical prophylaxis did not meet appropriate criteria. Moreover, mechanical prophylaxis was ordered in only two thirds of patients who met guideline endorsed indications. Although combination VTE prophylaxis strategies are not recommended in this patient population, almost a quarter of all patients had pharmacologic and mechanical prophylaxis prescribed. The potential implications of unnecessary use of mechanical prophylaxis include increased cost, patient discomfort, wasteful nursing time, and impedance on patient mobility. Efforts to reduce potentially inappropriate use of mechanical prophylaxis are needed.